Provider Demographics
NPI:1356870950
Name:GREEN ORAL SURGERY PLLC
Entity type:Organization
Organization Name:GREEN ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-406-1777
Mailing Address - Street 1:715 W BAILEY BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1279
Mailing Address - Country:US
Mailing Address - Phone:817-237-7557
Mailing Address - Fax:817-237-7585
Practice Address - Street 1:715 W BAILEY BOSWELL RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179
Practice Address - Country:US
Practice Address - Phone:817-237-7557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-07
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty